Improved COVID-19 Outcomes for Patients With Rheumatic Diseases

Patients with rheumatic and musculoskeletal diseases are more likely to suffer severe outcomes associated with coronavirus disease 2019 (COVID-19), however, the incidence of such complications has decreased as the pandemic has progressed, according to a recent comparative cohort study published in The Lancet Rheumatology.¹

Investigators sought to determine whether the rates of hospitalization, intensive care unit (ICU) admission, mechanical ventilation, acute kidney injury, renal replacement therapy, and death in patients with rheumatic and musculoskeletal disease and COVID-19 changed from the first 90 days of the pandemic (beginning January 2020) compared with the second 90 days (beginning April 2020). The team relied on data from TriNetX, a multicenter electronic health record, to gather information on individuals diagnosed with COVID-19 and their associated outcomes, and then performed a subgroup analysis for patients with rheumatic and musculoskeletal diseases specifically.

Investigators assessed outcomes within 30 days of a COVID-19 diagnosis and used an exposure score method to match 1:1 for demographics, previous hospitalizations, and laboratory results. The research team also took into account improvements in testing, supportive care, and treatment methods between the first 90 days of the pandemic and the second.

Rheumatic and musculoskeletal diseases examined included “rheumatoid arthritis, spondyloarthritis, systemic lupus erythematosus, systemic sclerosis, dermatomyositis, polymyositis, Sjögren's syndrome, other systemic connective tissue diseases, systemic vasculitis (including antineutrophil cytoplasmic antibody-associated vasculitis, Behçet's disease, polyarteritis nodosa, and giant cell arteritis), polymyalgia rheumatica, and gout.”

A total of 8540 patients with rheumatic and musculoskeletal diseases who had been diagnosed with COVID-19 were included in the study—2811 in the early cohort and 5729 in the subsequent cohort. Hospitalization risk was lower in the later cohort (32.4% vs 45.4%). Further, intensive care unit admission (7.9% vs 14.3%), mechanical ventilation (3.6% vs 9.1%), acute kidney injury (13.8% vs 20.7%), renal replacement therapy (.06% vs 1.2%), and death (4.5% vs 9.3%) were lower in the later cohort versus the earlier one. For those hospitalized, the combined risk of intensive care unit admission, mechanical ventilation, and death were also lower in the later cohort (30.7% vs 41.3%).

For those hospitalized, the mean ages were 65 years in the first cohort and 64 years in the second. The exposure score matched cohorts “were similar in terms of demographics, comorbidities, rheumatic and musculoskeletal disease diagnoses, creatinine, BMI, glucocorticoid use, oral disease-modifying anti-rheumatic drug (DMARD) use, and previous hospitalizations.”

Although the risk of severe outcomes among patients with rheumatic and musculoskeletal diseases and COVID-19 decreased over time, use of some therapeutics increased. Among patients in the exposure score matched hospitalized subgroup, 27 patients (2.5%) in the early cohort received remdesivir compared with 120 patients (11%) in the late cohort. Dexamethasone use was similarly up, with 80 patients (7.3%) receiving it in the early cohort compared with 270 patients (24.8%) in the late one.

Use of therapies such as tocilizumab and hydroxychloroquine, however, decreased in this patient population as the pandemic progressed. Forty-two patients (3.9%) and 473 patients (43.4%) received tocilizumab and hydroxychloroquine, respectively, in the early cohort compared with 32 patients (2.9%) and 112 patients (10.3%) in the late cohort.

Limitations, including misclassification, secular trends in ICD-10 documentation, patients who received subsequent care outside of the network, and availability of and access to COVID-19 tests, were accounted for throughout the study. Investigators do not believe that these limitations would be enough to skew the data between cohorts as their findings were consistent across all end points in their primary analysis. Additionally, changes in standards for hospitalization and mechanical ventilation procedures are not enough to negate the improvement in mortality rate between the 2 groups.

“In this large, population-based cohort study in the USA, we found improved outcomes for patients with rheumatic and musculoskeletal diseases after COVID-19 diagnosis in more recent months of the pandemic compared with earlier months, including lower risks of death, respiratory failure, and renal failure,” investigators concluded. “This finding is probably multifactorial, due to increased testing capacity allowing for detection of milder cases, improved supportive care, and improved treatments.”

The risks of severe complications for patients with rheumatic and musculoskeletal diseases have seemingly lowered as the pandemic continues to spread across the country. However, those with rheumatic and other autoimmune conditions remain at a higher risk when compared with the rest of the population. Findings suggested that “the risk of death remains substantial, with 5-6% of patients dying within 30 days of diagnosis of COVID-19.” Investigators continue to push for improvements in prevention and treatment in order to protect those with compromised immune systems.

Reference:

Jorge A, D'Silva KM, Cohen A, et al. Temporal trends in severe COVID-19 outcomes in patients with rheumatic disease: a cohort study [published online ahead of print, 2020 Dec 24]. Lancet Rheumatol. 2020;10.1016/S2665-9913(20)30422-7. doi:10.1016/S2665-9913(20)30422-7